Inpatient Rehabilitation during Intensive Refeeding in Severe Anorexia Nervosa

Abstract

Severe forms of anorexia nervosa are responsible for weight loss and life-threatening consequences. Refeeding represents a real psychiatric and somatic challenge. Physical activities are usually not recommended during intensive refeeding in order to avoid energy expenditure. This study assessed the interest in an early return to controlled physical activities, during a hospitalization in a Physical Medicine and Rehabilitation (PMR) department, including continuous nasogastric refeeding and psychiatric care. A total of 37 subjects aged 32 ± 11 years old performed inpatient physical activities during nasogastric refeeding initiated after intensive care. The physical activity program was adapted according to the hyperactivity of the patients. Evaluation parameters were weight, body mass index (BMI), body composition (fat, lean, and bone masses), and function (strength, balance, walking, ventilation). Patient satisfaction, re-hospitalizations, and physical activities continuation were assessed at 12 months of follow-up. Weight, BMI, and body fat increased significantly (+2.7 ± 1.7 kg; +1.0 ± 0.6 kg/m2; +1.7 ± 2.5 kg, respectively). Muscle strength increased even if the lean mass did not. Walking distance, balance, and respiratory function were significantly improved. Weight and fat mass gains did not differ according to the presence or absence of hyperactivity. At 12 months, 46% of the patients continued to be physically active, but 21% of the patients had been re-hospitalized. The early return to controlled physical activities in PMR hospitalization does not compromise the efficiency of intensive refeeding in severe anorexia nervosa patients.

Inpatient treatments for adults with anorexia nervosa: a systematic review of literature

“…Out of the 27 studies, 13 cited the presence of psychiatrists [ 33 , 36 , 37 , 39 , 41 , 43 , 46 , 48 – 50 , 52 , 54 , 56 ], 11 of psychologists [ 37 – 41 , 43 , 46 , 48 , 50 , 55 , 56 ], ten of nurses [ 39 , 41 , 44 – 46 , 48 , 49 , 54 – 56 ], seven of general clinicians [ 33 , 37 , 39 , 41 , 43 , 54 , 56 ], nine of dieticians [ 37 , 39 , 41 , 42 , 44 , 46 , 48 , 49 , 56 ], four of physiotherapists [ 42 , 46 , 49 , 56 ], two of occupational therapists and social workers [ 33 , 48 ]. Only 12 studies detailed the presence of a multidisciplinary group [ 33 , 37 , 39 , 41 – 43 , 46 , 48 , 49 , 54 – 56 ].…”

“…Among the reviewed studies, 18 provided information on the mean duration of inpatient stay, indicating 59.35 days [ 30 , 33 , 34 , 37 , 38 , 40 – 46 , 48 – 51 , 54 , 55 ]. Two studies mentioned that the patients could be referred from the emergency room [ 39 , 46 ], while another stated that they were transferred from an intensive care unit [ 49 ]. All the studies specified the type of ward, with 19 being specialist EDs inpatient units [ 30 – 33 , 35 , 36 , 38 – 46 , 48 , 51 , 55 , 56 ], three Psychiatry units [ 34 , 47 , 52 ], two Internal Medicine units [ 37 , 50 ], one Physical Medicine and Rehabilitation unit [ 49 ], and one Nutrition unit [ 54 ].…”

“…Two studies mentioned that the patients could be referred from the emergency room [ 39 , 46 ], while another stated that they were transferred from an intensive care unit [ 49 ]. All the studies specified the type of ward, with 19 being specialist EDs inpatient units [ 30 – 33 , 35 , 36 , 38 – 46 , 48 , 51 , 55 , 56 ], three Psychiatry units [ 34 , 47 , 52 ], two Internal Medicine units [ 37 , 50 ], one Physical Medicine and Rehabilitation unit [ 49 ], and one Nutrition unit [ 54 ]. Additionally, one study was conducted in two integrated Psychosomatic and Psychotherapeutic wards [ 53 ].…”

“…Regarding oral nutrition, two studies outlined three meals per day [ 40 , 43 ], two reported three meals plus two snacks [ 41 , 56 ], and other two specified three meals plus three snacks [ 39 , 44 ]. Meals were often taken in groups with assistance from nurses or dieticians during meals, according to 11 studies [ 33 , 38 , 40 , 41 , 43 – 45 , 49 , 54 – 56 ], although this was not recommended by two studies at the beginning of the treatment [ 33 , 38 ]. In case of incomplete feeding or insufficient weight gain, four studies reported administering direct supplementation with an oral or enteral hypercaloric solution [ 33 , 38 , 42 , 54 ].…”

“…In patients with BMI < 13 enteral nutrition via NGT during the first 48 h. Initial enteral caloric intake 10 kcal/kg. Objective of caloric intake 30 kcal/kg/day 18 Yamazaki et al 2021 [ 47 ] 13.58 n.r n.r Expected weight gain 1 kg/week, usage of supplementary enteral nutrition 19 Smith et al 2021 [ 48 ] n.r n.r n.r n.r 20 Dauty et al [ 49 ] 13.80 1.00 n.r > 500 g per week , weight monitoring twice a week, NGT at entry > 1500 kcal × 36 gg approximately, dietary consultations once per week, supervised meals 21 Young et al [ 50 ] 12.70 n.r n.r n.r 22 Fouladi et al [ 51 ] 14.60 5.33 n.r 3200–3400 kcal at discharge 23 Funayama et al [ 52 ] 13.40 n.r n.r Mainly oral nutritional rehabilitation, intravenous feeding sometimes used, less frequently NGT. Initial caloric prescription 600–1400 kcal/day, increased by 200 kcal/day.…”